Medical Management - Utilization Management RN 140-2015
RemoteUnited States
Job Summary
Conduct clinical review of utilization requests for outpatient, ancillary, inpatient, and post-acute services to assess medical necessity and appropriateness. Implement coordination of care opportunities for high-risk members and institutionalized populations while accurately documenting determinations and contacting providers within established timeframes. Identify cases requiring referral to the Medical Director, flag quality issues to leadership, and refer eligible candidates to Care Management programs. Collaborate with physicians to facilitate service provision across the health care continuum, perform accurate data entry, and participate in continuing education initiatives. Requires an active Oklahoma RN license with three years of acute care experience.
Required Qualifications
- Knowledge of managed care and associated group benefit plans
- Possess strong oral and written communication skills
- Ability to reason logically and to use good judgment when interpreting materials or situations
- Knowledge of community- based resources
- Must have excellent organizational skills and be able to perform multiple tasks
- Proficient in Microsoft applications
- Excellent time management and documentation skills
- Successful completion of Health Care Sanctions background check
- Graduation from accredited School of Nursing
- Current, active, unrestrictive license to practice as a Registered Nurse in the State of Oklahoma
Desired Qualifications
- Three years of acute care experience preferred
- Two years of experience working with population health preferred
- Previous discharge planning or case management experience preferred
- Managed care experience a plus
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